According to the Paperwork Reduction Act of 1995, no persons are required to respond to collection information unless such collection

displays a valid OMB control number. The valid OMB control number for this information collection is 1845-0048. The time required to complete this information collection is estimated to average 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to U.S. Department of Education, Washington, D.C. 202024651. If you have comments or concerns regarding the status of your individual submission of this form, write directly to Federal Student Aid, U.S. Department of Education, Students Channel Collections, 830 First Street, N.E., MS 5320, Washington, D.C. 20202

Form Approved: 03 /27 /2002 OMB Number 1845-0048 Approval Expires: 03 /31/2003

Federal Perkins Loan Program
(Formerly National Direct/Defense Student Loan)

Assignment Form
The borrower named below was issued a Federal Perkins Loan or a National Direct Loan, authorized under Title IV, Part E, of the Higher Education Act of 1965, as amended, or a National Defense Student Loan authorized under Title II of the National Defense Education Act. The institution is assigning all rights and title under such note or agreement to the United States Department of Education, without recompense as provided under Section 463(a)(5), 20 U.S.C. 1087cc. SECTION A – INSTITUTIONAL INFORMATION 1. Full Institution Name 5. Serial Number

2. Full Street Address of Institution

6. Entity Number (EIN)

3. City 8. Typed Name of Auth. Official 11. Typed Title of Auth. Official

4. State 9.CertificationDate (MM/DD/YYYY) 12. Telephone Number (Area Code)

7. Zip Code 10. Signature of Auth. Official 13. Alternate Contact

Certification: I understand that if I knowingly make a false statement or mis representation on this form in the course of assigning this defaulted loan to the United States Department of Education, I am subject to a fine of up to $10,000 or imprisonment of up to five (5) years or both under provisions of the United States Criminal Code, 18 U.S.C. 1001. SECTION B – BORROWER INFORMATION 14. Current or Last Known Name (Last, First, MI) 15. Previous Name(s ) (Maiden, Legal Change,
etc.)

16. Social Security Number

17. Date of Birth (MM/DD/YYYY)

18. Departure Date (MM/DD/YYYY) 22. Telephone Number (Area Code)

19. Current or Last Known Permanent Address (Number and Street)

20. City

21. State

23. Zip Code 27. Telephone Number (Area Code)

24. Work Address (es) of Borrower (Number and Street)

25. City

26. State

28. Zip Code

29. Name of Cosigner of Loan (Last, First, MI)

29A. Social Security Number of Cosigner

30. Current or Last Known Permanent Address of Cosigner (Number and Street)

33. Telephone Number (Area Code)

31. City

32. State

34. Zip Code

SECTION C- LOAN INFORMATION: HISTORICAL Type of Loan (Check Appropriate Space) 35. Perkins ___ 36. Direct ___ 37. Defense ___ 40. Date Last Grace Period Ended (MM/DD/YYY)

38. Applicable Interest Rate on the Loan _______% 41. Date of Default (MM/DD/YYYY)

39. Date of Last Advance (MM/DD/YYYY)

Was this loan ACCELERATED? (Check appropriate space.) If YES, provide date of acceleration. If NO, provide date this loan became fully mature (due-in). 42. YES ___ 43. NO ___ 44. Date (MM/DD/YYYY) ________________

Was this loan LITIGATED? (Check appropriate space.) If YES, provide date and attach judgement. 45. YES ___ 46. NO ___ 47. Date (MM/DD/YYYY) ________________

Borrower Repayment status (For use only by schools closing out program) 48. _________________________________ Reason this loan has been determined uncollectable. (Check Appropriate Space) 49. Hardship _____ 52. Refusal to Pay ___ 50. Incarceration ___ 53. Address Unknown ___ 51. Unemployment ___ 54. Other (Please Explain) 57. Principal Amount Repaid $ ___________________ 60. Collection Costs Repaid

SECTION D – LOAN INFORMATION: FINANCIAL 55. Principal Amount Loaned (Not Refunds) 56. Principal Amount Refunded $ ________________ 58. Principal Amount Cancelled $ ____________ 59. Principal Amount Outstanding (55 less 56, 57, & 58) $ ____________________ 62. Interest Cancelled

$ __________________ 61. Interest Repaid $ ____________ 64. Collection Costs/Penalty/Late Charges $ __________

$ ________________ 63. Interest Due

$ ________ $ ____________ 65. Total Amount Outstanding (Sum of Items 59, 63, and 64) $ ___________

SECTION E – CANCELLATION AND DEFERMENT INFORMATION Principal Percentage Interest Cancellations Granted for this loan Rate Cancelled Cancelled Type 66. 72. 78. 84. 90. 67. 73. 79. 85. 91. 68. 74. 80. 86. 92. 69. 75. 81. 87. 93.

For Services Performed
From (MM/DD/YYYY) To (MM/DD/YYYY)

70. 76. 82. 88. 94.

71. 77. 83. 89. 95.

Deferments Granted for this loan Start Date (MM/DD/YYYY) Type 96. 99. 102. 97. 100. 103. 98. 101. 104. End Date (MM/DD/YYYY)